Arthur H. Hertz/Orange Bowl Committeem MIAMIBEACH
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
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Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city board or
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on such
action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committee. The term
specifically inGudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
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BUSINESS NAME AND AC
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TELEPHONE NUMBER:
(Last) (First)
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SS (Number and Street) (City (State)
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EMAIL:
I. LOBBYIST RETAINED BY:
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(State) (Zip Code)
out this section If principal i a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~j/'j L (~ /9~S
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
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Issue to be lobbied escribe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED ~ (Pursuant to city code section 2-482(8)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an Impropriety, with any Clty personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B) An Financial, Familial or Professional Relationship
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(Zip Code)
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ,/1 ~!n p
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
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The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
"w - present or aendins~ award for goods, eauiament or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
application for chance of zoning maa desistnation or chance to the Citv's Future Land Use
Map?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of anot-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATI N: PRINCIPAL IDENTIFICATION: ~
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orm of Identification
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~ VII. SIGNATURE AND STAMP OF NOTARY:
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~ ~ ~ ~ Sworn to and subscribed~efore me
This ~" day of ~C/>>"
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Sig ature of Public Notary -State of Florida ~~ ~
Signature of Public Notary -State of Florida
~y ~'3 Notarization of Lobbyist's signature Notarization of Principal's signature ~~ L~ f-
TO BE COMPLETED BY CIT Y CLERK'S STAFF ONLY
Annual Registration fee: ]Yes [ ] No Amount Pald $ MCR Date Pald ~
Lobbyist Registration Form received and verified by:. /l /) ~~-
F:\CLER\LOBBYIST\Lobbyist Registration Form 32TOS.doc ~ Revised 0 /2 7/2008
I do solemnly swear that all of the foreg cts are true and correct and that I have read or am familiar with the
provisions contained in Section 2-48 a"Miami Beach ode and all reporting requirements.
Signature of Lobbyist:
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~ /~~'ylU/ ~~ _ 6~e/~ 7/
I understand that no later than October 1st of each year, I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
Signature: Date:
F:ICLERILOBBYIST1Lobbyist Registration Form 32708.doc